Thursday, February 28, 2013

Lesson Twenty: Prevention - Pack Light

"An ounce of prevention is worth a pound of cure."

Uh, yeah. And then some.

Goggles weigh 8 ounces. We're still working on the prosthetic eyes.

A watch cap, wooly pully, fresh socks, and fire starting kit weigh a pound, maybe two. A casket weighs about 80 pounds.

Carry your survival kit. I repeat, carry your survival kit. I repeat, carry your survival kit.
Pocket tin, less than a pound.
Belt kit, couple of pounds.
Casket, 80 pounds.

Your body is overwhelmingly water.
A bottle of water purification tabs weighs a couple of ounces.
A 5-star water purification pump or desalinating pump weighs a couple of pounds.

I can fix your shrapnel to the eye, sucking chest wound, broken arms and legs, traumatic head injury, dehydration, hypothermia, and shock a lot better if it never happens because you didn't break 27 safety guidlines, than if I have to start using an ambulance-load of Secret Medic Ninjitsu on all your little screw-ups.

It's a well-documented fact, that in the wilderness and in combat, the vast majority of all casualties are caused by a loose nut behind the trigger. Tighten yourself up, and safety-wire that thing, before you hurt yourself.

Wear your helmets, your seatbelts, your vests, both life- and bullet-resistant-, your goggles, your earplugs/muffs.
Do all the do's and avoid all the don'ts somebody smarter than you told you about.
Like the Doc told the cherry grunts in "Hamburger Hill", "If you want to get out of this place alive, you will listen to people who know!"

Yeah, you're a candyass, sugar-coated killer. You're also not blind, deaf, and all jacked up after the plane crashes/boat sinks/IED goes off/zombies attack.

Which means as the dust settles and the screaming starts, you can help be part of the solution, instead of part of the problem.
You can return fire conscious, instead of soaking up incoming fire as you lay there knocked out.
You can go home to your friends and family and kids and hobbies, instead of being hauled out in a plastic bag, or strung up from a bridge by your gonads, or getting a wreath tossed over the side because they couldn't find the body after the sharks and crabs ate it.

Any of those things might happen anyways, but if it does, you'll at least have had a chance.
If I was going to get thrown into a pit with a bear no matter what, and they asked whether I wanted a spear and a knife, or nothing, I know which option I'd chose. And it wouldn't be nothing but the firm resolve to taste very bad.

There are two certainties in life. The first is that any number of things in the big bad universe are trying to end yours, with no malice aforethought, simply the cold, unyielding facts of physics, the laws of nature, and random chance, and exactly zero regard for what a splendid all-around human being you are. Rocks don't fall on only bad people, and tigers and sharks express no preference for jerks over stand-up folks. Crocodiles snack on heathens and missionaries with equal relish.

So your good looks, sense of humor, and busy social register won't cut you any slack in the back of beyond, and you shouldn't expect it to do so either.

The second rule is that eventually, the Universe is going to win, and you won't be here.
Bring your stuff, follow the rules, and learn and practice what you know how to do, and you can put that day off an amazing amount of time so that by the time it happens, you're old and feeble enough that when Death comes knocking, it'll be a welcome rest and a new adventure, and not you screaming with your last breath that it isn't time to go yet. The former is much more pleasant. And the kicking and screaming almost never avails, because Death's sense of what's right usually has more to do with what you did before things went sideways than what you do afterwards.

So pack a small kit, and an ounce of common sense, and save everyone else having to haul your carcass out feet first.

Sunday, February 24, 2013

Lesson Nineteen: Survival Medical Kit

Everybody who's anybody writing about survival has taken a shot at concocting their medical kit for whatever survival-esque scenario one might imagine. Some of them are great, some are at least okay, and some are, to be charitable, rather optimistic.

The kit recommended in Lofty Wiseman's SAS Survival Guide is hard to beat for simplicity, utility, and compactness, even 25 years later.

Tylenol and ibuprofen, for pain relief/fever.
Imodium for diarrhea.
Broad-spectrum antibiotic.
Benadryl - an antihistamine.
Water sterilizing tablets.
Antimalarial prophylaxis meds.
Butterfly bandages.

He also lists potassium permanganate, which is a PITA to obtain in the U.S., but which has multiple excellent uses.

Note that several other items in his recommended survival kit like the mirror, matches and candle, needle and thread, scalpel/razor blades, magnifying glass, condom, salt and sugar packets, and pen and paper all have medical utility as well, at least secondarily or in extreme situations.

Given more space, I'd add

Neosporin antibacterial spackle.

Old school:{A military field dressing.
                 {A muslin triangular bandage.
                 {A 4" Ace type wrap.
 New School:[Combat Gauze hemostatic dressing.
                    [Israeli 4" bandage
                    [Asherman chest seal.

If I couldn't find the field dressing, a small stack of gauze 4x4s, a 3" gauze wrap, and a roll of medical tape would substitute.

As a rule, you should be able to stuff all of that, or whatever you concoct into something the size of a military 3-magazine pouch for M-16 mags, or something equivalent. (It's about 4x4x9 inches, for reference.) In an emergency, you'll either need a lot less, or a lot more, so that should do for 75% of situations. The other 25%, you won't use it at all, or you'll need to improvise what you don't have, or you're not going to make it no matter what you have. Unfortunate, but true.

If you're thinking about carrying less, when the shortfall becomes apparent, you'll have no one else to blame for your imminent decline except your own short-sightedness.

Don't be that guy.

Tuesday, February 19, 2013

Lesson Eighteen: TCCC TFC

Following on immediately after Care Under Fire, Tactical Field Care begins whenever things calm down enough to allow this level of care in the field. The fight may be over, there may be a lull, it may re-commence at any moment, and/or you may have a place of security and cover from immediate battlefield actions where secondary care of a casualty or casualties is appropriately rendered. You may have minutes to hours for this phase. Work like it was minutes. The tactical and medical situation may change at any moment, so work your casualties rapidly through the steps, and move on to the next one, and/or re-evaluate the ones you have, with a view towards getting any patients ready for the next, Evacuation, phase of care.

Casualties with an altered mental status should be disarmed immediately, before further care. Rifles, pistols, knives, grenades, pyro and demo. Everything. “Hey buddy, let me hold onto this for you while the doc checks you out” is a good way to approach it with conscious patients. At any rate, it’s embarrassing to have a patient who’s not in his normal state of mind attack your doc or others because you didn’t take away his toys. And if he’s later being evacuated, that gear is going to need to be re-distributed anyway.
TFC starts with M-A-R-C-H. The acronym is broken down as follows:

Massive hemorrhage control. If tourniquet(s) were applied during CUF, drive on. If not, apply any you need to. And if one wasn’t enough, a second CAT may be applied above the first one to control further bleeding from the already once-tourniquetted extremity.
Airway Management

You next want to establish and maintain a patent airway.
Conscious patients, esp. those with trauma to face, jaw, and upper airway, may be able to self-manage by sitting up and leaning forward. Let them.

Unconscious patients get the chin lift jaw thrust maneuver. If that isn’t enough, and they have no facial/airway trauma, deploy the “Nose Hose”, a nasopharyngeal (NP) airway. It looks like a trumpet. Lube it first, slide it into either nostril at a 90 degree angle, twist it into place, and tape it in place. It’s mildly uncomfortable, but tolerated, even by conscious patients. If one nostril won’t take it, try the other side. Don’t force it. Slow is better than trying to ram it in in a hurry. If the patient gags once it’s inserted to the flared end, it’s probably hitting the back of their throat and triggering the gag reflex. Withdraw it slightly, and resecure it.
Once either of these airways are accomplished, assess the patient for adequate breathing.

If both of these fail, the next option is a cricothyroidotomy. Describing this is fine, but you need to review diagrams to understand how to perform this intervention. (And if your patient is still conscious, some injectable lidocaine local anesthetic is a great idea!)
On males, there’s a prominent hump at the Adam’s apple. This is the thyroid cartilage. Just below this, there’s a depression (it’s roughly diamond shaped), then there’s another smaller harder ring, which is the cricoid cartilage. The flat diamond-shaped depression is the intended site for performing a “crike”. After prepping the patient’s skin with Betadine, a sterile scalpel should be used to make a vertical incision (that means from top to bottom) about ½ to ¾ of an inch long. You should be able to insert your gloved finger and/or a hemostat (scissor-looking clamp for non-medical types) to spread the opening slightly. If you have an 6.0 ET tube, insert it. If not, that failed nasal trumpet, or a fresh one, will also work. Once you’ve placed either into the hole, the patient should now have a new way to suck air and blow off CO2 if you did it right. Put some sterile gauze around the outside of the new wound you created to help stop any bleeding, and secure your new airway device with tape to keep it in place.

Place unconscious patients in the recovery position: Rolled onto left side, head resting on extended left arm, right arm and right leg drawn up and across the left limbs. This way, if they vomit, or have blood draining into their airway, they won’t choke on either.

Decompress tension pneumothorax. Anyone with penetrating chest or upper back trauma may have an air leak. The lungs work as a closed system. When air leaks in from outside, it gets between the lung and the chest wall, preventing full inflation. Eventually, the lung on the injured side will collapse, with the other lung pulling their airway structures to the better side. This is a tension pneumothorax.
To decompress the built up air inside the chest cavity, insert a 14G 3 ¼ “ needle catheter on the injured side* on the mid clavicular line (an imaginary up-and-down line halfway between the sternum and the shoulder), which is roughly above and slightly outside of the nipple, at the 2nd intercostal space (over the top of the second rib down from the collarbone). Ribs have their nerves, arteries, and veins in a notch underneath each rib, so by inserting over the top of the 2nd rib, you won’t hit these structures. The needle goes in at 90 degrees, and not pointed towards the heart. Air and/or fluid and blood may be ejected with pressure when this is done. If you have goggles or other eye protection, pop them on first if you hadn’t already been wearing them. Once the needle is in place, it should allow the trapped air out. Remove the inner metal needle, leaving the hollow tube (the catheter) in place, and tape the hub in place to continue doing its job.

Seal open chest wounds with an occlusive dressing.

So find the original cause of the problem, and apply an Asherman Chest Seal (ACS) or similar device, or an air-occlusive dressing, over the wound(s).
*Note that patients can get wounded on both sides, get tension pneumothorax on both sides, even from one wound, and/or need multiple chest decompressions on the injured side(s) and multiple chest seals/occlusive dressings. All of these are appropriate field medical interventions under combat conditions to prevent treatable causes of death.

Assist breathing/oxygenation.  Place unconscious patients in the recovery position. Conscious patients may wish to sit upright. If you have supplemental oxygen or bag valve masks, serious airway injury patients may require assisted ventilations, from an uninjured/less-injured buddy when possible to allow you to deal with other casualties.

Assess any issues with bleeding, and tourniquet and Combat Gauze placement.

Mark the time the tourniquet was applied indelibly on the CAT. A proper tourniquet should completely occlude pulses beyond where it is placed. Don’t loosen tourniquet once applied. Never remove a tourniquet on an amputated limb, or if the casualty is in shock, or if they will get to treatment in 2 hours or less, or if the tourniquet has been in place for 6 hours or longer.
If casualties have torso wounds not suited for treatment with the CAT, now’s the time to break out your Combat Gauze and stuff it into any open wounds. Apply direct pressure for at least 3 minutes once the gauze is applied. Do NOT remove pressure of the gauze to “check” to see if it’s working. You’ll only waste the gauze, and have to re-start the whole process. That'll be a problem if things get sporty again, so do it right the first time.

Once the time is up, observe for continued bleeding. If it continues, more gauze. Then pressure wrap with a field dressing, an Israeli 4” or 6” bandage, and/or ACE wraps or Coban-style self-adhering bandages.

Remember you’re treating notable hemorrhaging, not applying bandaids and 4x4s to superficial wounds at this point.

Any casualties in shock, or seriously at risk for it, like torso GSWs or major wounds, should get IV/IO access and fluids. I’m not covering this here and now, beyond telling you yet again that you need serious training to learn this beyond what a post on the internet can accomplish. Not least of which is the required hands-on supervised practice that can, in a couple of hours, get you to where you could start an IV if you had to, and none of which I can provide online in a blog. TAKE A SERIOUS CLASS.

The takeaway point I can give you is that the best way to treat shock due to blood loss is to prevent the blood loss in the first place. Dumping Hextend and LR into a patient who’s entering shock are a distant second to stopping the bleeding in the first place.
Aggressive early treatment vastly outperforms aggressive late treatment.

Head Injury/Hypothermia
Head injury patients need their O2 saturation maintained at greater than 90%. Whether you’re bagging them, or adding supplemental oxygen, keep their sats up. This is also why you need a pulse oximeter, even one of the $50 specials from the drugstore.

Remove wet clothing, and cover the casualty, top and bottom, to prevent heat loss. Shock and hypothermia are a lethal combination.
Other considerations

Eye trauma
WEAR YOUR FRIGGIN’ EYE PROTECTION, and avoid the problem. For those who didn’t, the injured eye should be covered with a rigid shield (not a pressure dressing, which can squeeze the fluid out of an injured eye and result in  loss of the eye.

Monitor pulse ox in patients with brain injury, major trauma, airway compromise, shock, or unconsciousness or altered mental status. Know that altitude decreases normal sea level pulse ox from 98% @ sea level to 86% @ 12K’ altitude in normal healthy individuals, and the decrease in available oxygen for the body is real. Casualties at altitude are thus at greater risk for notable hypoxia.
After MARCH, assess and treat all other wounds on all casualties. Expose the casualty using trauma shears to remove clothing, and check for wounds all over, top, bottom, and sides.

Patients capable of self-care may self-medicate with Mobic (if carried) and Tylenol, per TCCC dosages and guidelines. Aspirin and ibuprofen decrease clotting for 7 days after taking, and should be avoided for combat personnel for this reason.
Patients out of the fight are normally cared for using Rx IM/IV medication requiring diligent monitoring by the medic, per protocols.

Splint fractures and check pulses afterwards. SAM splints are your friend.
Burns Cover with dry sterile dressing, wrap with hypothermia blankets, treat for pain, and initiate fluid therapy for burns greater than 20% body surface area.

NO battlefield CPR. 100% failure rate for CPR, even for civilians with traumatic full arrest in non-combat environment. Dead is dead. Focus medical care efforts and resources on the salvageable living patients. Exceptions: hypothermia, electrocution, near-drowning. Bilateral needle decompression for tension pneumothorax rule-out is advised, may save a life, and won’t do any harm to a fully arrested patient.
Communicate with your patients, and reassure them as you reassess them.

Document patient condition, care and treatments rendered, and ensure the record gets passed along to higher levels of care when the patient is evacuated.

{Note: I won't be covering the Casualty Evacuation phase. If you're in the military, the training you receive on CASEVAC will be far more thorough than anything you'll find here. If you're not, casevac consists of using commercial or improvised litters until you get to a pack mule, truck, van, or phone to call for an ambulance, so going into 9-line medevac requests is kind of pointless. If you're hung up about it, take the class.}

Monday, February 18, 2013

Lesson Seventeen: TCCC CUF

Lesson Seventeen: Tactical Combat Casualty Care - Care Under Fire

For those that asked, the military has gone to TCCC specifically because medical aid while both victim and medical personnel are being shot at is, obviously, a wee bit different than doing care at the side of the road at a traffic accident, or in a hospital.

After losing what was then a lot of guys, in Mogadischu during what's become known as the "BlackHawk Down" incident, the Army, and all the military services, started looking for a better way of doing things than simply following care guidelines written for guys jumping out of an ambulance on the interstate.

TCCC is what they came up with.

The first stage is Care Under Fire. And it's stoopid simple.

1. Return fire and take cover.
Not necessarily in that order. The point is that when you're taking fire, the best first aid is returning fire and gaining fire superiority, while putting something between you and the bad guys that stops bullets.

2. Direct and/or expect the casualty to stay engaged as a combatant if appropriate.
If rounds are going both ways, and they're shooting back, let them drive on.

3. Direct casualty to move to cover and apply self-aid if able.
Self explanatory, and the key words are "if able".

4. Try to keep the casualty from sustaining additional wounds.
 No CPR, QuickClot, or jumping up to go get your buddy in the 10-ring of the kill zone.

5. If they can, they should apply the CAT tourniquet or equivalent to bleeding extremity wounds.
If they can't, putting on a tourniquet for appropriate bleeding is the one and only approved intervention at this stage for anyone else to perform.
You don't need to do or remember anything else besides shoot, get to cover, and tourniquet, for Care Under Fire.

Move to cover, return fire, tourniquet on (if necessary).
Cover, fire, tourniquet. Lather, rinse, repeat.

That's it. You're done.

Almost like Uncle Sam knew they were teaching skillz to the 8th grade level, and knew that when you get that adrenaline dump from world-class fight-or-flight, everyone - everyone - gets three levels faster, stronger, and stupider.

Sunday, February 17, 2013

Lesson Sixteen: Primary Survey

Lesson Sixteen: Assessment In A Hurry – The Primary Survey

 Springing from a private question, one of the topics I'd planned to hit eventually was this exact subject.

When it was taught to me my instructors always put us on I-395, on the backside of Yosemite, somewhere between Barstow and Bishop. Because other than Death Valley, it's the closest thing you'll get to the middle of nowhere.

So there you are, and unfortunately, Harry Superdoctor doesn’t pull up and offer to help. It's just you, the kit you brung, and the two twisted heaps of Detroit and Japanese steel tangled in the middle of the road ahead, complete with an abundance of patients.

Take a deep breath. Look at your two hands. With these hands you're going to do the exact same thing as Dr. Harry would have done (perhaps a bit slower, but darn near as well) and possibly save a life or two.

You remember your ABCs. In fact, you've been reading all the prior lessons, and you remember your SR?ABCs.

Safety: You determine that the scene is safe. Nothing's on fire nor about to be, and there's no traffic. In fact, that's rather a bummer, because another helper would be nice about now. As Superchicken always told Fred, "You knew the job was dangerous when you took it." And you first put on your set of trusty barrier gloves (latex or other-than. In fact, even leather work gloves are better than bare hands.)

Rescue?: No one needs to be pulled out imminently.

While you're pondering these first two, you're doing a quick scene survey, and getting a mental head count of victims.

You see there are four (which is at least three more than you'd prefer. Two people in one car have extricated themselves, and they're walking around, looking at each other and their new car. They can wait.

Car Number Two has two people as well. The passenger has a bloody nose and some cuts from broken glass, but she's walking and talking, so you point her to the side of the road, and ask her to have a seat.

As you get to the driver's side, you see the driver, not moving much. Time to get to work.

You're first going to do 8 things in the next 20 seconds.

{___} Observe respirations. Normal, fast, or slow.

Normal is 12-20 per minute. Normal looks normal. Practice counting on regular people, using your watch. Count for 20-30 seconds and triple/double it for your per minute count. On seriously injured people, count for a whole minute -- but not yet.

{___} Introduce yourself: "Hi. I'm Joe, and I know first aid/am an EMT/RN/MD/stayed at Holdiay Inn Express/watched an episode of ER once. I'm going to help you."

{___} Obtain permission to treat. If they say no, stop. But by not directly asking for their permission, (“I’m going to help you”, not “Can I treat you?”) you've cleverly put them in an implied consent position if they don't stop you. Their response will either be immediate, or not. In noting it, you're actually CHECKING FOR CONSCIOUSNESS.

They'll be at one of four levels:

Alert Noting what's going on around them. Most of us live here.

Verbal They respond when spoken too, but aren't alert. Think of your teenaged children when their favorite show is on, or a guy who's "not quite there". Injured/ill people can be at this level frequently.

Pain They only respond to physical/painful stimuli, as when you tap them on the shoulder; or perhaps need to either moderately rub their sternum (breastbone) with your knuckles, or squeeze a couple of their fingers, which are both mildly painful -- without being torture. Popping an ammonia ampule under someone's nose is torture. Don't do it.

Unconscious They don't respond to anything.

Remember AVPU (av-poo) when assessing Level Of Consciousness. Which you’ve just done.

Now, let's talk about consent for a minute.


If you tell them your level of training, and ask if it's okay to examine/treat them, and they say yes, you have informed consent. This only applies with legal-aged, unimpaired adults, and certain minors. Check your local laws.

If you tell them your level of training, and they don't refuse, you have implied consent.

If they're unconscious, you get to assume that they would agree to being helped if they could, because an ordinary, prudent person would, so that's also implied consent.

All of the above will work, from a Good Samaritan/legal standpoint.

With minors, you generally can't do anything except things which are necessary to save life or limb without the parent/guardian's informed consent. (e.g. you can do CPR, but not put on a band-aid. Go figure.)

If you attempt to touch someone after they say "Don't touch me," it's simple assault (in my state). If you actually make physical contact at all, it escalates to battery. Leaving a patient after starting care, without turning them over to higher care (fire department paramedics or ambulance, etc. can be considered patient abandonment.

These would be bad forms of first aid.

There are exceptions, which we'll get to in a minute.

Good Samaritan laws generally hold you to the level of action/care that a similar reasonable and prudent person, with similar training and equipment, would have done in this same situation.

I'm not a lawyer, just a practitioner. I've treated thousands of patients as both a volunteer and a paid professional, and never been sued. (SO far, in 20 years, thank you Jesus!) But I'm still young, and it could happen someday. So I strongly urge you to learn and know the standards of care and Good Samaritan coverage/principles in your own state.

Exceptions: A person not alert and oriented because they're injured/drugged/intoxicated can't give consent nor competently refuse treatment. And if someone becomes combative, you're allowed to abandon care rather than risk injury. Just back off, and wait for them to pass out from whatever cause (brain injury, blood loss, etc.). Then you have implied consent again, and can get back to work.

Nota bene that you cannot club them into unconsciousness to achieve the same state of affairs, no matter how much better for them this might be, how much they might deserve it, nor how much personal satisfaction it might give you.

After introducing yourself and obtaining consent for further treatment, ask them their NAME and their AGE.

A) Because calling everyone "buddy" gets old. Learning their name helps show professionalism, concern, and build some rapport.

B) Because it makes a difference in care if they're 35 or 75.

{___} Ascertain their CHIEF MEDICAL COMPLAINT. "Hit head", "hurt left arm", etc. Not "that idiot swerved in front of me and wrecked my car".

FYI:  AGE, SEX, and CHIEF COMPLAINT is 3/4ths of any fire/paramedic dispatch on any call. You're already there, assuming you can tell a male from a female. The other 1/4th is LOCATION. We'll get to that in a bit.

{___} Do a quick check under their body from head to toe for gross bleeding. Using those gloved hands, feel gently under them, and see if you come back with bloody gloves. That's it.

{___} Do a quick (gentle, but firm) check on top and sides of body for wounds/deformities. Holes, tenderness, bones poking out their body.

This should all take about 20 seconds. (And note that in 20 seconds, clever fellow you, you've covered Airway, Breathing, and Circulation.

I made this easy. You only have one victim to concentrate on. (Really, you have four, but I made them simple.) Suppose you had four, all equally injured?

You'd stop, and repeat this process for each one. And write down Name, age, sex, chief complaint, level of consciousness, and ABCs for each one. Then you'd focus on your more, or most, serious patient.

In this way, you'd see the entire situation, and not get sucked into helping someone who might be a relatively stable minor injury like a head laceration, and miss the guy not breathing.

Once you've seen all your patients, you are prepared to make a report, if possible.

Have someone call 9-1-1, and report a sex, age, and chief complaint on all patients, generally including their level of consciousness. This way, they know whether they need to send the whole world to you, or just one ambulance.

But, you're on lonely 395, so it's going to be awhile before anyone comes to help.

The good news is you've only got one patient (I'm not an ogre; but Life isn't always this fair. Be prepared.)

Now, using your Calibrated, Highly Developed Brain, with Loads of Common Sense, and an Incredible Sense of Calm Professionalism (even if this is your first accident), you're going to prioritize your patients (in this case, one), and starting with the most serious one, work your way through the rest of your primary survey. In less than 5 minutes.

Warning: This will require "STUFF."

Required items:

STUFF You’re Going To Need In Your Kit list

In most cases, TWO FUNCTIONING HANDS (gloved!!), and CLEAR VISION.* (See flashlight, below.)

A WRISTWATCH, visible, with either a sweeping second hand, or seconds which tick that you can count along with. (roll the glove cuff back on this gloved hand)

A STETHOSCOPE that you know how to use.

A BLOOD PRESSURE CUFF that you know how to use.

A SMALL FLASHLIGHT. Either a little penlight, or ideally, a small hands-free headlamp. NOT a Surefire X-200 Weaponlight or the like. We want to see them, and their pupils, not melt their corneas.

PAPER and PEN/PENCIL to write information down.

This tallies up to almost $25 worth of equipment, all reuseable except for the gloves, and all highly stable and weather resistant if kept in a small case the size of a shaving kit, with which you can assess 99% of patients with equal or better accuracy than *I* can in my gazillion-dollar, 21st Century Emergency Room. Cross my heart, I promise.

{___}Level of Consciousness

We already covered AVPU. Now, for those who were A or V or P, we want to know how ORIENTED they are. So we ask them their

_____Full Name _____ Where (they are) _____ When (today's time, day of week, of month, the month, the year) _____ What (happened)

A person who knows their name, where they are, what happened, and what date/time it is is "ALERT and ORIENTED TIMES FOUR" (AOX4) in Medicalese. Or 3, or 2 or 1. If a person can't name the day, try the date. Then try the month. Then ask the year. See how fuzzy they really are. The last thing most people lose, mentally, is their own name. A patient who is alert, but completely confused may be drunk, impaired, or seriously injured or ill. The brain is the most sensitive organ, so pay attention to LEVEL OF CONSCIOUSNESS and ORIENTATION, and re-assess it for CHANGE over time which could indicate improvement, or worsening of condition.

{___}Skins Signs 

We're looking at color, temperature, and moisture. ideally, we're hoping for pink, warm, and dry, rather than cool, pale, and clammy. Persons with darker skin can be assessed on (unpainted) nailbeds on the hands or toes, and palms, for color.

{___}Respiration  _____ Rate _____Depth _____ Rhythm _____ Adequate tidal volume

Rate: How many times per minute. Normal rate is 12-20 for adults. Less than 8/min or more than 30/min are bad. Note that children breathe faster.

Depth: Shallow, Normal, or Deep.

Rhythm: Regular, or Irregular. Not Disco or Jazz. Regular is good. Irregular probably isn't good.

Adequate Tidal Volume: Are they getting enough air, or getting worse, turning blue, etc. Oh, and is it equal on both sides of their chest?

{___}Pulse _____ Rate _____ Strength _____ Rhythm

Rate: Rates are variable across the lifespan. Average adults are 60-100. Kids you'll need to research -- it'd take me too long to cover here. 100-200 is a useful range from newborn to adolescents. Some adult athletes are in the high 40s to 50s, because their hearts are in superb shape. Less than 40, or more than 140, for a resting adult, is generally a bad thing.

Strength: Thready, Shallow, Weak, Normal, Bounding. As usual, we want Normal.

{___}Blood Pressure Expressed as "XXX over XXX" the Systolic pressure (while the heart's pumping) over Diastolic (while the heart is at rest). Check the arm for injuries before measuring it. Learn how to do blood pressures, select and place cuffs, and auscultate (listen) or palpate (feel) for readings by taking a course that teaches the skill. It's waaaaaay easier than you think, and you can practice on friends and family to keep the skill sharp. Learn how to do this NOW.


_____Size (in mm) _____ Equal (to each other) _____ Reactive to light -- or not (using that SMALL penlight, shined into and out of the iris). Note that BOTH should shrink when the light is shined into EITHER eye. It takes four checks to confirm this for both eyes. And while you're there, do they have contact lenses, or any blood, injuries or foreign bodies in the eye?

{___}Medical History

We want any four of these answered, at minimum:

_____ Allergies (to medicine or food) I'm not going to give them any cats or flowers, so that's far less important.

_____ Medications they take all the time, or today/recently. Including anything they bought for "recreational" use, as well as RX or OTC meds.

_____ Chronic conditions  Like diabetes, seizures, high blood pressure, heart attacks, strokes, etc.

_____ Major or recent surgeries

_____ Doctor If they regularly see one, or any specialists, like heart, lung, kidney, or cancer docs, among others.

_____ OB/GYN  For females of child-bearing years (10-60 in my book): Are they, or might they possibly be, pregnant? If so, how many times, how far along are they, etc.?

_____ Trauma  Prior, or the one you're dealing with now

_____ Other Medical history/information

Important note: You are RECORDING all this information as you get it in your NOTES. That’s the whole point of asking for it.

That's it. 

It takes less than 5 minutes (with a minimum of practice) to do all these steps on any given patient, assuming they cooperate.

You will have, at that point, completed a History and Physical Assessment equal to anything you'll get in a hospital on each patient you do this for.

And the more times you practice or do it, the sharper, quicker, and better you'll get at it. Doctors are thrown into this for their last 2 years of medical school, and their intern year. So with a few thousand tries, they've obviously got a leg up on you. But this baseline Primary Survey done competently and adequately, is all anyone could expect from you, and goes a tremendous way towards assessing and focusing your (and higher) treatment, and deciding treatment priorities for multiple patients in any emergency.

Back in my fabulous volunteer wilderness first aid course, we were required to be able to demonstrate doing a full patient assessment, Primary and Secondary, covering 143+ separate points of information, in under 15 minutes.

Missing anything on the Primary, or more than 19 items on the Secondary, was an automatic No Go. And we had to do it twice.

I saw persons like myself, with ZERO prior medical background, practice and pass this standard time after time after time. After failing their first attempts, time after time. Failure in practice is good. The embarrassment helped me to remember the things I'd forgotten, so I didn't forget them again. That's why observed practice works. Do it!

I've just told you what the Primary Survey entailed. It may look like a lot, but it really isn't much at all.

In another Lesson, I'll cover the Secondary Survey.

It's up to you to practice.
It's the only way you're going to learn this.

Saturday, February 16, 2013

Lesson Fifteen: Medications

Lesson Fifteen: Medications

As promised, here it is.

As threatened, here are your Important Advisories:

Repeat after me:
1) I am not a doctor. I am not a pharmacist. I do not have the medical training, nor legal authority to officially diagnose illness, nor prescribe or dispense prescription medication.
2) I will know and consider my own allergy status and that of people I treat BEFORE rendering any further treatment.
3) I will read and heed all label directions.
4) I will consult my own doctor and/or pharmacist before taking any medication, or providing it to those under my care, such as my own minor children.
5) I understand that failure to follow those guidelines of both legal necessity and plain common sense makes me a fool, dangerous to myself and others, legally and morally liable for my actions, and expect to be pointed out and laughed at as such, including in open court, should I neglect them, regardless of any and all contrary excuses.

General exemplar: If your friend asks you for some aspirin/Tylenol/Motrin for a headache, and you hand him a package from which he extracts same, you are usually not considered to be prescribing nor dispensing medications.

When your friend says he has a pain at the bottom of his rib cage, and you tell him it's indigestion, hand him a couple of Tums, and he takes them, then falls over dead from a massive heart attack, you have diagnosed, prescribed, and dispensed medication. See advisory 5 above.

I promise you with every fiber of my being, what I've told you so far is equally, if not more, important than anything else you'll get out of this information regarding medications. Really. Cross my heart, and hope to die.

I'm putting this at the beginning for two reasons, one minor, and one major.

The minor one is that if anyone, anywhere in the galaxy, ever attempts to tell the world they did something because Aesop, the World Authority On All Things Medical, told them they could, I will point to it, especially Advisory 5, and then point and laugh. And then I'll get medieval on you.

The major one is because if you take on the huge responsibility of caring for people, even in an emergency or SHTF scenario, you have to remember a couple of things to protect yourself as well, and most importantly your patient.

The first is, Good Samaritan laws provide immunity from legal harm (criminal and civil) for helping someone -- with two important boundaries.

First, anyone can be arrested, and anyone can be sued, for whatever they do. Good Samaritan Laws merely provide a means of affirmative legal defense to make it impossible for the other side to win.

Secondly, they do so ONLY if you, the Good Samaritan in question, are within the boundaries of what a prudent average person with a similar level of training WOULD HAVE done, in your shoes. This is yet another reason why doing field appendectomies and amputations, throwing in a few stitches, or handing out Rx medications, is a B.A.D. idea in all but the most dire Zombie Apocalypse-type circumstances.

The first line of the Hippocratic Oath, which doctors no longer recite upon graduation, but which every one of them knows nonetheless, is one with 3000 years of common sense behind it:

“First, I Will Do No Harm.”

In other words, don't make the problem worse by anything you do. Hippocrates was no dolt.

And one more time: Every medication has contraindications – in layman’s terms, reasons to NOT use them – not least of which is a personal allergic reaction. NOT knowing the whys and why nots of the following medications is YOUR fault, because I’ve told you and you’ve promised to LOOK THEM UP FIRST. This is deadly serious, and I expect if you’re reading this far, you will treat it as such.

Now, to the meat and potatoes: What I carry in my everyday kit, and why.

The BOMB. A drug company executive once lamented its discovery, as boiled willow bark, too early on in history. The number of uses probably would have guaranteed it would still be Rx-only otherwise. It can be used (in adults) for fever control, pain relief, and to thin the blood (inhibit prostaglandin synthesis for sticklers) in patients who may be having cardiac problems like a heart attack. For children's fevers, it should generally NOT be given, due to risks of certain side effects.

That would be Tylenol to the uninitiated. The fever-reducer with the fewest side affects, considered especially appropriate for children. BEWARE: Many modern OTC (that's over the counter) medications have acetaminophen snuck into them too. Including some things sold by Motrin (see below). Thus you could take a daytime cold/flu med, a nighttime one, and some Tylenol, and end up triple-dosing yourself on acetaminophen. If you want to die a slow agonizing death after liver failure, overdose on acetaminophen. Or, heed Advisory 3, and note the list of active ingredients in ANYTHING you or anyone takes.

Motrin, Advil, and generics, etc. to the public. Like aspirin and acetaminophen, it also reduces pain, and is an anti-pyretic (fever-reducer). Like acetaminophen, it is better for children (once they're over 6 months, and have no conditions which would contraindicate it) for fever reduction. Because ibuprofen and acetaminophen work on fevers differently, they can be safely alternated without double-dosing. A typical fever treatment recommendation is acetaminophen at 12 and 6, and ibuprofen at 3 and 9, following recommended dosages. Your child gets fever reduction every three hours instead of every 6, so they feel better. Fevers lasting longer than 3 days, or unresponsive to treatment (don't go down despite medication) for lesser time periods should still be seen by a doctor/ER. Be safe, not sorry.

Ibuprofen, like aspirin (above) and Aleve (naproxen) are all also in the family of NSAIDs - Non Steroidal Anti-Inflammatory Drugs. That means besides pain and fever reduction, they will reduce swelling. That's what makes ibuprofen, to me, niftier than aspirin or acetaminophen -- it helps with swelling related to strains, sprains, etc., even in the absence of pain.

Note that where use for children/infants is anticipated, liquid forms are available. If you carry this form of ibuprofen or of acetaminophen, learn how to properly calculate/administer dosages. And realize, regardless of age-based (rather than size-based) dosing guidelines, that a 12-year old who's 6'2" and 160 pounds is not the same dose as a 12 year old who's 4'10" and 93 pounds.

Abbreviated sometimes as BZK, sold commercially as Bactine. It kills germs in wounds, and it doesn't make your patient scream. See Lesson One.

Otherwise known as Betadine. Kills germs and disinfects, as noted in Lesson Thirteen. Also note it comes in both “scrub” strength, and “solution” strength. You want solution. Scrub is for killing cooties on surfaces and instruments, not putting on or in wounds.

triple antibiotic ointment
AKA Neosporin. Good superficial wound spackles, with the same provisos from Lesson Thirteen.

Isopropyl, as opposed to vodka or scotch, and usually carried as wipe pads, not the bottle. It's flammable - use with caution. But it will clean INTACT skin, and kill some (not all) germs rapidly, so it's good  to use to clean instruments like tweezers, scissors, needles, etc. before and after use. But it takes 10-20 minutes scrubbing and soaking to truly sterilize them. It's not magical on contact.

Or honey. For diabetic emergencies, when suspected. If someone's sugar is critically low, it will save their life. If it's critically high, a few more points isn't really going to matter. If you suspect diabetes, you can put or pour some under the tongue or between the cheek and gums, and it will be absorbed sublingually without risk of choking. I keep cake frosting because it tastes better than medical glucose (blecch!), and also some honey packets from a restaurant retailer. They found honey in the pyramids in clay jars with wax seals just as fresh as it was when laid down 3,500 years ago. Whatever bees put in their spit, it's good stuff and keeps forever. Just don't spill it in your kit!

For heat emergencies. A very small amount is plenty in a quart to a gallon of water, for oral rehydration. Larger quantities will simply induce vomitting, which is probably not a good idea. Go easy.

My choice is Imodium AD tablets. They pack small, keep well, and can be lifesavers, let alone vacation-savers. If you risk Traveller's Curse, carry the anti-curse.

There are numerous types and versions. My personal choice is Benadryl. It cuts itching in allergic responses, and helps to reduce swelling. Most induce drowsiness. This can be good if you're trying to sleep, but not if you're trying to drive or simply stay awake.

I like Tums for simple acid reduction, because it's basically a calcium salt. But famotidine (Pepcid) and similar family H2 Blockers (Tagamet, Zantac, Axid) not only cut down on acid production, they also reduce the body's histamine response, which is part of anaphylaxis (life-threatening allergic response). The part that helps kill you in serious responses.

{Nota bene: ANY medication used to treat a potential life-threatening anaphylactic (allergic) reaction ONLY BUYS YOU TIME. And quite possibly NOT VERY MUCH. If you use Benadryl, Pepcid, or any form of epinephrine (EpiPen, AnaKit) in treating someone’s allergic reaction, or anytime there is wheezing, tightening in the throat, difficulty swallowing or speaking, you WILL call 9-1-1 ambulance and/or get to an ER ASAP. When the meds you gave wear off, whether in a few minutes or several hours, your patient/friend/family member will possibly be right back where you started, and you’ll have one less dose of meds to cope with this. And possibly also a rapidly closing airway making swallowing the second dose problematic or impossible. If you medicate, you MUST transport. GET THEM TO A HOSPITAL, NOW!}

sterile saline wash
As previously noted, a generic sterile non-preserved saline solution can not only wash eyes and contact lenses, but it'll blast out dirty wounds nicely far away from running water. It runs about 75 cents to a dollar per bottle, and stays sterile until you open it by piercing the tip with the cap.

Oil of cloves
A 1 oz. bottle of this can be used to apply a couple of drops to a cotton ball or Q-tip, and placed on/in a cavity, for a temporary toothache remedy.

Your personal RX and OTC meds
Obviously, if you have any personal conditions which would necessitate Rx medications, you are strongly urged to have a minimum of a one-month supply in your personal emergency kit/supplies. You can rotate this stock, so that your monthly purchase is always the one you put in your kit, and your old kit medication becomes what you use as you rotate stock out. Thus nothing is wasted, and you ALWAYS have a fresh, 30-day cushion on your nitroglycerin, insulin, gout pills, and/or whatever else you may need. Which is harder -- rotating your meds, or being 1000 miles from home, after your doctor's office is under 10 feet of water or buried in rubble, and having no one (and possibly no pharmacy either) to dispense a fresh supply?

Plan ahead. Murphy doesn’t care about your excuses.

You may also decide that, for your comfort, you'd like OTC (over the counter, no prescription) meds I haven't included. Cough/sore throat lozenges, sunscreen, chapstick, etc. and multitudinous combination cough/cold/meds like Dayquil, Nyquil, etc, ad infinitum. Frequently referred to by pseudo-hardcorps types as “snivel meds”. It’s true that you want them because you have the sniffles, but acting like you’re a candyass for wanting/using/carrying them is false bravado and idiotic. I carry them, because I've reached the wisdom to realize that being miserable isn't noble, and being less than 100% may cost you your life from distraction, among other things. Thus you should carry them too. If there are any medications you've "just gotta have" that I haven't listed, by all means include them. And be as familiar with them as the ones I have listed, for your own sake. It's also a sterling idea to keep all your personal medications, whether Rx or OTC, separated from your kit meds, and appropriately labeled as such. It could save confusion, or even a stretch in jail for carrying unlabeled Rx controlled substances. Trust me, this is never funny nor inconsequential when sitting in the TSA/FBI/DEA holding cell (or foreign equivalent) at an international airport or port of entry.

That’s IT.

Unless you or a close family member has a known allergic reaction to something common (like bee stings, seafood, etc.) I would NOT recommend getting/wheedling/conniving your private MD to write an Rx scrip for an EpiPen or the like.

Epinephrine is a cardio-active drug commonly used to treat heart attacks. Improper/inappropriate use of epinephrine can KILL someone, and if you aren't at least a paramedic with ACLS training or higher, I don't have time to list the ways how. Put it in the DUMB category, except for the indicated use above.

I'm not going into any other Rx medications whatsoever, because 3 people might benefit, whereas 3000 will make foolish assumptions, and 2 of them will kill somebody, and invoke my name.

If you're bright enough to comprehend higher levels of medication administration, and foolish enough to attempt doing it without any further training or licensure, you don't need my help to get in trouble, and then try to drag me down with you. To say nothing of what you may do to your patient.

Last note: Be aware that this list is written with names standard in the USP - United States Pharmacopeia. Mexico, Canada, the UK, the EU, and everyone else tend to insist on making up their own generic names for common medications -- even for acetaminophen! I assume no responsibility for those reading this in far-flung locales who don't check on things in their own country's terminology.

I highly recommend you consult previously listed resources, such as nursing drug guides, the PDR, etc. or various websites like WebMD or [] to fill in gaps in your knowledge on this subject, and answer further questions.

Medication and its usage (along with germ theory and antisepsis) is largely the difference between all medicine after 1860 or so, and everything that went before. Modern medicine without modern medication would be largely impossible, for almost everything we do.

If you're going to attempt, at a layman's level, to relieve your own and other family member's pain and suffering, you have a duty to learn all you can in order to do it safely, legally, and properly, using due common sense, diligence, and prudence. Doing so is a very praiseworthy act of the highest order of personal (and civil) responsibility. That's why society generally respects doctors and the like.

Doing so without due diligence simply makes you a witch doctor with access to a modern drugstore.